Sports Med (2013) 43:819–837
DOI 10.1007/s40279-013-0061-x
REVIEW ARTICLE
Football Injuries in Children and Adolescent Players: Are There
Clues for Prevention?
Oliver Faude • Roland Rößler • Astrid Junge
Published online: 31 May 2013
Ó Springer International Publishing Switzerland 2013
Abstract Football (soccer) is the world’s most popular
sport with most players being younger than 18 years.
Playing football can induce beneficial health effects, but
there is also a high risk of injury. Therefore, it is necessary
to implement measures for preventing injuries. The present
review analyzes and summarizes published scientific
information on the incidence and characteristics of football
injuries in children and adolescent players to arrive at
sound conclusions and valid considerations for the devel-
opment of injury-prevention programs. A literature search
was conducted up to November 2012. Fifty-three relevant
scientific publications were detected. Thirty-two studies
fulfilled the inclusion criteria for pooled analysis. Addi-
tional information from the remaining 21 studies was
considered where appropriate to obtain a broader per-
spective on the injury problem in children and youth
football. Training injury incidence was nearly constant for
players aged 13–19 years, ranging from 1 to 5 injuries per
1,000 h training. Match injury incidence tended to increase
with age through all age groups, with an average incidence
of about 15 to 20 injuries per 1,000 match hours in players
older than 15 years. Between 60 and 90 % of all football
injuries were classified as traumatic and about 10–40 %
were overuse injuries. Most injuries (60–90 %) were
located at the lower extremities with the ankle, knee, and
thigh being mostly affected. The frequency of upper-
extremity and head/face injuries was higher in those studies
O. Faude (&)
R. Rößler
Institute of Exercise and Health Sciences, University of Basel,
Birsstr. 320B, 4052 Basel, Switzerland
e-mail: oliver.faude@unibas.ch
A. Junge
FIFA-Medical Assessment and Research Centre (F-MARC),
Schulthess Clinic, Zurich, Switzerland
that analyzed match injuries only. The most common
injury types were strains, sprains, and contusions (10 up to
40 % each). There is some evidence that the risk of trau-
matic injuries and, in particular, of sustaining a fracture,
contusion, or concussion was higher during match play
than in practice sessions. Fractures were more frequent in
children younger than 15 years than in older players. About
half of all time-loss injuries led to an absence from sport of
less than 1 week, one third resulted in an absence between
1 and 4 weeks, and 10 to 15 % of all injuries were severe.
Separate data for players under the age of 11 years are
almost absent. Maturation status seems to have an influence
on injury characteristics, although evidence is not conclu-
sive at this time. Three main areas seem to be of particular
relevance for future prevention research in young football
players: (1) the substantial number of severe contact inju-
ries during matches, (2) the high number of fractures in
younger players, and (3) the influence of maturation status
and growth spurts.
1 Introduction
Football (soccer) is the world’s most popular sport with
respect to active players as well as to spectators [1]. The
International Federation of Association Football (FIFA)
survey in 2006 estimated that approximately 265 million
people were playing football worldwide. The viewing
audience (in-home and out-of-home viewers) of the final of
the 2010 FIFA World Cup South AfricaTM was estimated
to be in excess of one billion people [2]. Every 4 years, the
world becomes transfixed on a small fraction of the playing
population that is made up of professionals, but by far, the
highest proportion of participants (22 of 38 million offi-
cially registered players) are under the age of 18 years.
820
From 2000 to 2006, the number of registered youth players
increased by 7 % worldwide [1].
During recent years, it has been shown that playing
football can induce considerable beneficial effects on
health risk factors as well as on cardiovascular and neu-
romuscular fitness from childhood to older age [3–7]. Thus,
playing football has a great potential to support a healthy
lifestyle. However, football is a high-intensity sport with
frequent changes in movement, velocity, and direction as
well as high impacts and many situations of direct contact
between players, which pose the risk of injury. Hence,
there are also potential negative outcomes both for indi-
vidual players as well as for the healthcare system [8–13].
Adverse events may discourage children from playing
football or may lead parents to forbid their children to play
football. Therefore, it is necessary to implement preventive
measures to reduce the risk of injury, and, thus, to support
the health benefits associated with playing football.
Sound epidemiological data on the frequency and
characteristics of football injuries are a necessary pre-
requisite to develop and evaluate promising prevention
programs [14, 15]. Many epidemiological studies on foot-
ball injuries in professional and adult players of both sexes
have been conducted [16–21], and a consensus regarding
methodological standards for epidemiological studies on
football injuries was published in 2006 [22]. Information
regarding children and youth players seems less clear. Giza
and Micheli [23] summarized most of the existing literature
with regard to football injuries up to 2001 emphasizing the
pediatric population. The included publications varied
considerably with regard to methodological quality and
approach, injury definition, and various other influencing
factors, and, thus, the conclusions were very general [23].
Several new studies on injuries in children’s and youth
football have been published during the past decade. Thus,
the present review aimed at analyzing, updating, and
summarizing the published epidemiological data on foot-
ball injuries in children and adolescent players (B19 years)
to arrive at comprehensive conclusions and valid consid-
erations for the development of injury-prevention programs
in children’s and youth football as well as for directions of
future research in this area. A particular objective was to
analyze available information on injury incidence, mech-
anisms, location, and type of injuries as well as injury
severity.
2 Literature Search and Analysis
A literature search was conducted using the Medline
database PubMed up to November 2012. In order to obtain
the widest range of injury topics, the keywords ‘‘soccer’’ or
‘‘football’’ together with ‘‘injur*’’ in combination with
O. Faude et al.
‘‘youth,’’ ‘‘junior*,’’ ‘‘adolescen*,’’ ‘‘pediatric,’’ or
‘‘child*’’ were used in Boolean logic for query. All titles
(N = 833 without duplicates) were reviewed (OF and RR),
and publications that were obviously not appropriate (e.g.,
case studies, clinical evaluation and treatment, rehabilita-
tion, etc.) were excluded. The abstracts of the remaining
articles were read to determine if relevant data were pre-
sented. Citation tracking of key primary and review articles
was also undertaken to obtain further pertinent articles.
Studies were included in a pooled analysis if they were
published in an international peer-reviewed journal and if
injury incidence was reported relative to the hours of
football exposure. Studies analyzing injuries in different
sports or age groups were included in this analysis when
separate data for football injuries in players younger than
19 years of age were available. Studies using retrospective
questionnaire analysis were not included in the pooled
analysis. After the evaluation of titles, abstracts, and full-
texts, 53 scientific publications remained that were relevant
with regard to the objective of the present review. Of those,
32 fulfilled the criteria as outlined above (Table 1). While
several studies for players older than 13 years were pub-
lished, only few studies analyzed injuries of younger
children, and comprehensive data on football injuries of
girls were also lacking. Twenty-one studies reported injury
rates either in relation to the number of athletes exposed or
as simple frequencies and therefore did not fulfill the
inclusion criteria for the pooled analysis (Table 2). Addi-
tional information from those studies, however, was also
regarded where appropriate to obtain a broader perspective
on the injury problem in children and youth football. Three
studies investigated preventive measures in the targeted
age group [24–26], and the data of the control groups were
included in this review. Two further studies [27, 28] used
data reported in previous publications [25, 29], and, thus,
were not included in the present analysis.
The present review is mainly based on the results of the
32 studies summarized in Table 1. All relevant information
in these studies with regard to the objectives of the present
review were extracted by two authors (OF and RR) and
analyzed. For the analysis of injury mechanisms, body
parts, and injury types, studies were separately evaluated
when only tournament data (i.e., only match injuries) were
reported. If possible, relevant information (incidences or
relative frequencies) were calculated from original data.
Confidence intervals (95 % CI) for match and training
incidences were calculated.
3 Incidence of Injury
The overall injury incidence varied mostly between 2 and 7
injuries per 1,000 h of football for players aged
Table 1 Summary of studies on injury characteristics in children’s and youth football reported as outdoor injury rates per 1,000 h of football
Reference Country Study design Duration of Injury definition Number of players Level of play Age in Sex Number
data collection (teams) years of injuries

Aoki et al. Japan Prospective cohort study 1 year Time loss (more than 1 week 301 (6 teams) NA 12–17 NA 425
[45] (January– absent)
December)
Backous USA Prospective cohort study Five 1-week Time loss (at least one practice 1,139 Subelite 6–17 Male 216
et al. [55] football session or match) and
camps female
Brito et al. Portugal Prospective cohort study One season Time loss (more than 1 day 674 (28 teams) Subelite 11–18 Male 199
[34] (August– absent)
June)
de Loes and Sweden Prospective study of 1 year (1984) Attendance to a physician and 1,342 Subelite 8–18 Male 66
Goldie sports injuries in a registration as sports injury and
[74] municipality female
Football Injuries in Children and Adolescent Players

Elias [41] USA Prospectively recorded 1988–1997 Medical attention (presentation *89,500 players Subelite Under-12 to Male 3,548
injuries during to Cup medical facility) (5,373 teams) under-19 and
tournaments female
Emery et al. Canada Prospective cohort study One outdoor Medical attention and/or 317 (21 teams) Subelite 12–18 Male 78
[11] season incomplete session and/or and
(13 weeks) missing next training/match female
Froholdt Norway Prospective cohort study One season Medical treatment or missing 1,879 (121 teams) Subelite 6–16 Male 200
et al. [44] (April– part of training/match and
October) female
Inklaar et al. The Prospective cohort study Second half of Reduction in football activity 232 (18 teams) Subelite 13–18 Male 43
[40] Netherlands a season or need for treatment or
adverse effects
Johnson Great Britain Prospectively recorded 2001–2007 Not specified, probably 292 Subelite 9–16 Male 476
et al. [33] injuries medical attention
Junge et al. New Zealand Prospective cohort study One season All physical complaints 145 (12 school Subelite 14–18 Male 261 (81
[35] (March– associated with football and teams) time-
August) separate analysis for time- loss
loss injuries injuries)
Junge et al. Switzerland Prospective intervention 1 year Physical complaints caused by 93 (7 teams) Subelite 14–19 Male 111
[26] study (data for control soccer lasting for more than (mean
group only) 2 weeks or time loss (match 16.3)
or training session)
Junge et al. Czech Prospective cohort study 1 year Time loss (at least 1 week) 311 Subelite 14–18 Male 187
[59] Republic, (includes data of [38])
France,
Germany
Kakavelakis Greece Prospective cohort study 1 season Time loss (more than 1 day 514 (24 clubs) Subelite 12–15 Male 209
et al. [36] (August– after onset)
June)
821
Table 1 continued
822

Reference Country Study design Duration of Injury definition Number of players Level of play Age in Sex Number
data collection (teams) years of injuries

Kibler [61] USA Prospective injuries Weekend Removed from or missing a NA Subelite 12–19 Male 179
surveillance tournaments game due to an injury or and
(1987–1990) medical attention female
Le Gall et al. France Prospectively recorded 1998–2006 Time loss (more than 1 day 119 Elite; national 15–19 Female 619
[31] injuries absent) training center
Le Gall et al. France Prospectively recorded 10 seasons Time loss (at least 48 h) 233 Elite national Under-14 Male 588
[30] injuries at national (1995–2005) team (mean
football institute 13.3; SD
0.3)
Le Gall et al. France Prospectively recorded 1993–2003 Time loss (at least 48 h) 528 Under-14, -15, 13–15 Male 1,152
[32] injuries at national and -16 elite
football institute national teams
Maehlum Norway Analysis of injuries 6-day First-aid treatment (medical (1,348 teams) Subelite 11–18 Male 411
et al. [43] tournament attention) and
female
McNoe and New Zealand Prospective cohort study One winter Medical attention/self- 539 Community level 13–17 Male 822
Chalmers season treatment or missing and
[46] (April– subsequent training/match female
September)
Müller-Rath Germany Retrospective analysis of Two seasons Time loss (match or training First season: 20 (1 Elite 16–18 Male 48
et al. [48] documented injuries session) team), second
season: 27 (1 team)
Nielsen and Denmark Prospective cohort study One season Time loss (at least one practice 30 (2 teams) NA 16–18 Male 27
Yde [39] (January– session or match) and
November) female
Nilsson and Norway Analysis of injuries 6-day First-aid treatment (medical 25,000 (1,549 teams) Subelite 11–18 Male 858
Roaas [47] tournaments attention) and
(1975 and female
1977)
Peterson Czech Prospective cohort study 1 year Any tissue damage caused by 180 Subelite 14–18 Male 363
et al. [38] Republic football regardless of the
consequences
Rosenbaum USA Prospective injuries 2-day Medical attention (tent or on- 3,350 (243 teams) Subelite 9–18 Male 68
et al. [63] surveillance tournaments field) and
(2006 and female
2008)
Schmidt- Denmark Retrospective analysis of One season Handicaps a player during 496 (3 clubs) Subelite 12–18 Male 312
Olsen et al. prospectively (10 months) playing or requires special
[68] registered injuries attention or prevents play
O. Faude et al.
Table 1 continued
Reference Country Study design Duration of Injury definition Number of players Level of play Age in Sex Number
data collection (teams) years of injuries

Schmidt- Norway Prospective injury 5-day First-aid treatment (medical 6,600 (410 teams) Subelite 9–19 Male 346
Olsen et al. surveillance tournament attention) and
[42] (1984) female
Söderman Sweden Prospective cohort study One outdoor Time loss (absent from at least 153 (10 teams) Subelite 14–19 Female 79
et al. [37] season one practice session or game)
(April–
October)
Soligard Norway Prospective intervention One season Time loss (next match or 837 (41 teams) Subelite 13–17 Female 215
et al. [25] study (only data of the (March– training session) (mean
control group) October) 15.4; SD
0.7)
Spinks et al. Australia Prospective cohort study 12 months First-aid treatment 744 Primary school 5–12 Male 20
[75] children and
Football Injuries in Children and Adolescent Players

female
Steffen et al. Norway Prospective cohort study 1 season Time loss (no full participation 2,020 (109 teams) Subelite Under-17 Female 526
[29] (March– for at least 1 day) (mean
October) 15.4; SD
0.8)
Timpka Sweden Prospective cohort study One season Medical attention and/or 1,800 (93 teams) Subelite 13–16 Male 44
et al. [65] incomplete match and/or
missing next match
Yde and Denmark Prospective cohort study One season Time loss (at least one practice 152 (1 club) Subelite \10–18 Male 62
Nielsen (February– session or match)
[60] October)
NA data not available or not applicable, SD standard deviation
823
Table 2 Summary of studies on injury characteristics in children’s and youth football: reported injury rates per athlete’s exposure, reported indoor injuries, or retrospective questionnaire
824

analysis
Reference Country Study design Duration of data Injury definition Number of Population Age in Sex Number of
collection individuals characteristics years or injuries
(number of school
groups) level

Adams and USA Population-based July–December Presentation to emergency Estimated Injured players, 5–19 Male Estimated
Schiff [9] descriptive study 2000 department 144,604 level NA and 144,604
female
Baxter-Jones Great Britain Retrospective interview 2 years Medical attention or reduction 64 Elite players 8–16 years Male NA
et al. [56] analysis (1987–1989) in the amount of sports and
activity female
Berger- France Injuries reported to Rhône- One season Any incident reported to the NA (all teams) Subelite teams 8–17 Male 1,214
Vachon Alpes Soccer Association (September– Rhône-Alpes Soccer of Rhône- and
[58] insurance company May) Association Alpes female
Association
Dahlström Sweden Retrospective postal survey One season Medical attention or time loss 767 (4 clubs) Subelite players 8–18 Male NA
et al. [101] on injuries (December (at least one training session and
2005– or match) female
November
2006)
Darrow et al. USA Cohort study 2 academic years Medical attention and time loss NA (100 High school High Male 183
[70] of more than 21 days representative players school and
high schools) female
Emery and Canada Cluster randomized One indoor Medical attention and/or 364 (28 teams) Subelite 13–18 Male 79
Meeuwisse controlled trial (only data season removal from a session and/ indoor and
[24] of the control group) (October– or time loss from full soccer female
March) team participation
Emery and Canada Prospective cohort study on One indoor Medical attention and/or 102 (9 teams) Subelite 13–17 Male 35
Meeuwisse indoor injuries season incomplete session and/or ?40 and
[49] (20 weeks) missing next training/match individual female
participants
Gianotti et al. USA Descriptive analysis of 1994–2004 Presentation to hospital 32,149 Injured players, 5–19 Male 32,149
[8] hospital presentations level NA and
female
Hoff and USA Retrospective One season Missing (part of) game/practice 455 (49 teams) Subelite 8–15 Male 46
Martin [51] questionnaire (exact duration or limited playing ability and (outdoor)
NA) female 74
(indoor)
Kucera et al. USA Prospective cohort study 1997–2000 Missing part of next training 1,483 (212 Subelite players 9–18 Male 905
[66] session or match teams) and
female
Kujala et al. Finland Data from national sports 1987–1991 Reported to insurance company NA Injured players, Up to 19 Male 4,065
[102] injury insurance registry subelite and
female
O. Faude et al.
Table 2 continued
Reference Country Study design Duration of data Injury definition Number of Population Age in Sex Number of
collection individuals characteristics years or injuries
(number of school
groups) level

Leininger USA Descriptive analysis of 1990–2003 Presentation to emergency 41,278 Injured players, 2–18 Male 41,278
et al. [10] nationally representative department level NA and
football injuries female
Lindenfeld USA Prospective observation in 7 weeks Leaving game or stop playing NA Subelite Up to Male 33
et al. [50] an indoor football arena due to an injury or medical 18 years and
attention female
Powell and USA Observational cohort study Academic years Any injury causing cessation of 2,963 Injured players; NA Male 3,536
Barber- (1995–1997) participation, fractures, high school and
Foss [72] dental injuries, and mild level female
brain injuries (not necessarily
resulting in cessation of
Football Injuries in Children and Adolescent Players

exercise; NAIRS definition)

Price et al. Great Britain Prospective cohort study Two seasons Time loss (at least 48 h) 4,773 (29 Subelite players 9–19 NA 3,805
[57] (1999–2001) football club
academies)
Radelet et al. USA Prospective cohort study 2 years (1999/ Coach on field, first-aid 482 (40 teams) Subelite players 7–13 Male 47
[103] 2000) treatment or removal from and
participation female
Rechel et al. USA Cohort study 1 academic year Medical attention and time loss NA (100 High school High Male 706
[69] of more than 1 day representative players school and
high schools) female
Schiff [67] USA Retrospective One season Time loss (at least 1 day 103 (10 teams) Community 11–14 Female NA
questionnaire absence) level
Schmikli The National survey on injuries 6 years Physical damage or physical 1,241 Subelite players 4–17 Male 104
et al. [104] Netherlands and physical activity (2000–2005) hindrance related to football
training or competition
Sullivan et al. USA Prospective cohort study One season Any medical problem resulting 1,272 (80 Subelite players 7–18 Male 34
[105] from football and preventing teams) and
participation female
Yard et al. USA Descriptive epidemiologic 2005–2007 Medical attention and restricted NA (100 high High school High Male 1,524
[62] study participation schools) players school and
female
NA data not available or not applicable, NAIRS national athletic injury/illness reporting system
825
826
13–19 years. Overall incidence is dependent on the ratio of
training and match exposure, and, thus, separate data for
practice and games should be reported and analyzed [22].
Table 3 provides an overview on training and match inci-
dences of outdoor injuries as related to age groups and sex.
Training injury incidence was nearly constant for players
aged 13–19 years, with most numbers ranging from 1 to 5
injuries per 1,000 h of training [25, 29–39], while younger
players had lower incidences. Match injury incidence ten-
ded to increase with age through all age groups, with an
average incidence of about 15 to 20 injuries per 1,000
match hours in players older than 15 years [26, 35, 38, 40–
43]. The ratio of match to training injuries varied between
1.2 [11] and 11.5 [44], with most numbers between 3 and 6
[25, 26, 31, 32, 34, 35, 37–39, 45, 46]. No relevant dif-
ferences in injury incidence of boys and girls were
apparent.
Some of these conclusions were based on only very little
available information. Exact data on training injuries were
rare, in particular for girls and children younger than
13 years. Some studies reported data for the under-13
category, but separate and reliable information for players
11 years and younger was almost completely missing. The
summarized figures are rough estimates, and the exact
numbers differed considerably between studies. The
sometimes huge variations are most likely due to meth-
odological differences in injury definitions, data collection
strategies, and observation periods. For instance, Nilsson
and Roaas [47] analyzed all injuries that received first-aid
treatment during a 6-day tournament in Norway. The high
number of minor injuries (which mostly do not result in
time loss) caused the high injury rate in this particular
study. If minor blisters and abrasions were excluded from
analysis, the incidence was considerably lower and within
the range of the values reported in other investigations
[47].
Most studies analyzed subelite players. Only a few
studies investigated players of the highest level of the game
[30–32, 48]. Le Gall and coworkers looked at injuries at the
French National Football Institute and reported overall
injury incidences of about 5 to 6 injuries per 1,000 h of
football in male under-14 to under-16 players [30, 32] as
well as in female under-17 and under-19 players [31].
Training incidences were about 4 to 5 injuries per 1,000
training hours for both sexes, and match incidences were
between 10 and 14 injuries for the boys and 22.4 injuries
per 1,000 match hours for the older girls. Müller-Rath et al.
[48] reported a low overall injury rate of 2.4 injuries per
1,000 playing hours in one team in the highest German
under-19 division. Unfortunately, separate information for
training and match injuries was not presented. In summary,
injury incidence in elite youth players is mostly in the
upper range of reported values for subelite players. In this
O. Faude et al.
regard it has to be mentioned that medical service in elite
youth players is more comprehensive as compared to the
subelite level, and, thus, the probability that all injuries
were documented and appropriately treated is more likely.
Therefore, it seems justified to conclude that elite youth
players might have a similar injury risk as subelite players.
In comparing injuries occurring during indoor and out-
door football, a conclusive appraisal is not yet possible. In
2006, Emery and Meeuwisse [49] observed no relevant
differences between indoor and outdoor football. Another
investigation reported extraordinary high injury rates for
playing indoors (up to 60 injuries per 1,000 match hours for
under-15 girls) [50]. In addition, Hoff and Martin [51]
found about 4.5 times higher incidences for playing indoors
as compared to outdoors. The latter two studies were
published a long time ago, and indoor football arenas have
changed considerably since then (e.g., through the devel-
opment of modern surfaces). Recent studies showed no
relevant differences in injury incidence rates between
natural grass and artificial turf when playing outdoors in
adolescent and adult players [29, 52–54]. Further research
seems warranted to clearly assess whether incidence rates
playing indoors are higher.
Four studies analyzed injury risk with regard to maturity
status in pubescent children [30, 33, 55, 56]. Although not
significant, injury incidence was found to be higher in early
maturing as compared to late-maturing players in two
studies [30, 33]. In addition, Backous et al. [55] reported
that skeletally mature but muscularly weak boys were more
susceptible to injury compared to peers of the same chro-
nological age. Early maturing players showed a higher
number of tendinopathies, groin injuries, and reinjuries,
whereas late-maturing boys had significantly more os-
teochondroses, and a higher incidence of severe injuries
leading to an increased injury-related lay-off time [30]. In
contrast to those studies, Baxter-Jones et al. [56] observed
no influence of pubertal status on the number and severity
of injuries in high-level youth football players. Considering
that about one third of all players of one age category were
not within their normal maturity category [33], it seems
warranted that the influence of maturity status on injury
characteristics be investigated in more detail in future
studies. This is well justified because the valid assessment
of maturity status is expensive and difficult and various
different methods were applied in the mentioned studies.
For instance, the early study of Backous et al. [55] used
height and grip strength to estimate maturity status, and,
thus, the obtained results need to be interpreted very
carefully. Moreover, it is possible that late-maturing boys
are underrepresented within a specific population whereas
early maturing boys are overrepresented. In future, this has
to be critically considered and standard methodological and
statistical procedures have to be established to assess the
Table 3 Outdoor injuries per 1,000 h of training and match play with regard to age group and sex
Age range (age group)a Both sexes Boys Girls
Match Training Match Training Match Training

17–19 years (under-19) 1.5 (0.8, 2.7) [11] 0.2 (0.0, 1.1) [11] 7.1 (3.7, 10.4) [34] 1.2 (0.5, 1.9) [34] 10.6 (9.5, 11.9) [41] 4.6 (4.2, 5.1) [31]
8.6 (6.4, 11.6) [43] 3.6 [39] 15.9 (11.2, 22.5)[43]
13.5 (12.5, 14.5) [41] 4.7 (3.8, 5.8) [38] 22.4 (19.6, 25.6) [31]
14.4 [39] 47.2 (33.0, 67.5) [42]
20.6 (16.4, 25.9) [42]
23.6 (19.5, 28.6) [38]
28.3 (18.3, 43.9) [40]
15/16 years (under-17) 9.9 (6.8, 14.5) [11] 1.2 (0.4, 3.7) [11] 2.1 (1.5, 2.9) [65] 1.1 (0.4, 1.8) [34] 8.3 (7.5, 9.2) [29] 1.1 (0.9, 1.3) [29]
3.7 (0.4, 7.0) [34] 3.7 (2.4, 5.6) [35] 9.1 (6.7, 12.4) [37] 1.5 (1.1, 2.1) [37]
14.2 (12.0, 16.8) [32] 3.8 (3.3, 4.3) [32] 9.6 (8.1, 11.3) [25] 2.4 (1.9, 3.0) [25]
Football Injuries in Children and Adolescent Players

16.1 (8.9, 29.1) [40] 4.1 (3.3, 5.1) [38] 17.7 (16.2, 19.2) [41]
16.1 (15.0, 17.2) [41] 5.7 (4.4, 7.3) [26] 38.6 (30.8, 48.4) [42]
16.2 (12.6, 20.9) [35]
19.2 (15.9, 23.1) [42]
19.6 (15.8, 24.2) [38]
20.0 (15.2, 26.3) [26]
13/14 years (under-15) 8.5 (5.6, 12.8) [11] 7.2 (4.2, 12.1) [11] 2.6 (1.4, 5.0) [65] 0.7 (0.5, 1.4) [34] 16.9 (15.5, 18.5) [41]
5.6 (4.6, 6.8) [36] 3.3 (2.7, 4.0) [36]
6.1 (2.8, 9.4) [34] 3.7 (3.3, 4.2) [32]
9.5 (7.9, 11.5) [32] 4.1 (3.7, 4.6) [32]
10.4 (8.6, 12.5) [32] 4.7 (4.3, 5.2) [30]
11.8 (10.1, 13.7) [30]
11.8 (10.9, 12.8) [41]
12.8 (6.4, 25.6) [40]
\13 years (under-13) 2.0 (1.3, 5.4) [34] 0.5 (0.2, 1.2) [34] 0.9 (0.5, 1.6) [42]
9.3 (6.8, 12.7) [43] 1.4 (1.3, 1.6) [33] 12.6 (11.0, 14.5) [41]
9.4 (7.1, 12.6) [42]
10.5 (9.0, 12.2) [33]
11.2 (10.0, 12.5) [41]
827
828 O. Faude et al.

7.0 (4.1, 11.8) [46]

association between maturity status and injury risk in more

0.4 (0.2, 0.8) [44]

detail.
Training Few studies used population-based descriptive approa-
ches to analyze injury risk from several thousand presen-
tations to American emergency departments [8–10]. These
data are of interest because they provide a broader per-
spective. However, it must be stressed that minor injuries,
which are frequent in football, were not included in these
20.5 (16.6, 25.3) [43]

51.7 (41.4, 64.6) [46]

13.0 (8.8, 19.2) [43]

analyses because such injuries usually are not presented to

7.6 (5.6, 10.3) [63]
4.6 (3.2, 6.6) [44]

emergency departments. Injury risk was reported to be on

average between 1.5 and 2.5 injuries per 1,000 children per
44.0 [47]

year [9, 10], and injury rates increased with age [9, 57, 58].
Match
Girls

Over a period of 13 years, the rate of injuries presented to

an emergency department for children older than 5 years
varied from just below 6 (1990) to 7.6 (2000) injuries per
1,000 football participants [10]. Gianotti et al. [8] showed
0.5 (0.3, 0.8) [44]

6.8 (5.3, 8.7) [46]

that 60 % of all football injuries presented at an emergency

department resulted from unorganized football.
Training

1.7 [60]

4 Mechanisms of Injury
Age group was either defined by the reported average age of the cohort or if the age group was explicitly given

About 40 to 60 % of all injuries were due to contact with

36.8 (32.4, 41.8) [46]
11.2 (9.3, 13.4) [43]

another player or with an object (e.g., ball, ground, or

7.3 (5.0, 10.7) [63]
9.1 (7.2, 11.5) [43]
5.4 (4.4, 6.6) [44]

posts; Table 4) [11, 29, 35, 55, 59–61]. Yard et al. [62]
reported that contact injuries were dominant during match
23.0 [47]

play whereas noncontact injuries more frequently occurred

9.9 [60]
Match

during practice sessions. This is in line with the findings of

Boys

Price and colleagues [57] who observed that most training

injuries were caused by running while match injuries were
predominantly caused by tackling and collision. Gianotti
0.5 (0.3, 0.6) [44]
6.8 (5.4, 8.5) [46]

et al. [8] found that player-to-player contact increased with

age, whereas contact with a structure, object, or the ball
decreased. Between 60 and 90 % of all football injuries in
Training

young players were classified as traumatic (i.e., caused by a

single traumatic event), and about 10 to 40 % were overuse
injuries (i.e., the result of repetitive microtraumata without
a clearly identifiable event; Table 4) [11, 25, 26, 29, 31,
39.3 (35.2, 43.9) [46]

35–37, 40, 44, 48, 59, 63]. This considerable range might
95 % confidence intervals are given in parentheses
2.4 (2.0, 2.8) [61]
5.2 (4.3, 6.1) [44]
7.4 (5.8, 9.4) [63]

be due to variations in the definition of overuse injuries,

and the difficulty in assessing whether there was an acute
Both sexes

underlying event [64]. Those studies that analyzed injuries

during tournaments (i.e., match injuries only) reported the
Match

highest frequencies of traumatic injuries and the lowest

rates of overuse injuries (Table 4) [42, 63]. Similarly, the
number of recurrent injuries was reported to be about 4 %
Age range (age group)a

in three studies [30, 31, 34], whereas three other studies

No specific age group

observed recurrence rates of nearly 20 % and higher [29,

Table 3 continued

63, 65]. Again, this variability might be attributed to

inconsistencies in the definition of a recurrent injury, and
the difficulty in diagnosing it when medical service is not
very comprehensive as is the case in youth football at a
subelite level. Uniform definitions that are feasible in
a
Football Injuries in Children and Adolescent Players 829

Table 4 Distribution of injury mechanisms

Reference Mechanism of injury (%)
Contact Overuse Trauma Recurrent

Studies analyzing injuries over a season (match and training injuries combined)
Backous et al. [55] 47
Brito et al. [34] 43 57 4
Emery et al. [11] 46 10 90
Froholdt et al. [44] 62 24 77
Inklaar et al. [40] 35 65
Junge et al. [35] 52 15 85
Junge et al. [26] 38 37 63
Junge et al. [59] 46 17 83
Kakavelakis et al. [36] 63 20 80
Le Gall et al. [31] 13 86 4
Le Gall et al. [30] 3
Müller-Rath et al. [48] 35 65
Söderman et al. [37] 34 66
Soligard et al. [25] 35 24 76
Steffen et al. [29] 58 13 87 19
Timpka et al. [65] 68 18
Yde and Nielsen [60] 51
All studies, median (range) 51 (35–68) 24 (10–43) 77 (57–90) 4 (3–19)
Studies analyzing injuries during a tournament (match injuries only)
Kibler [61] 56
Rosenbaum et al. [63] 10 90 26
Schmidt-Olsen et al. [42] 5 95

children’s football are urgently warranted to arrive at more
homogenous and conclusive results in this regard. This is
particularly relevant because players with a history of
injuries showed an increased risk for new injuries (but not
necessarily the same one) [11, 66].
5 Location and Type of Injury
Most injuries (60 to 90 %) were located at the lower
extremities with the ankle, knee, and thigh being mostly
affected (Table 5). The proportion of injuries in these
locations varied considerably between studies, possibly due
to inconsistencies in definition and documentation as well
as low sample sizes. Injuries to the lower leg and foot/toe
were less frequent (about 10 % each). Approximately 10 %
of all injuries were related to the trunk including back
complaints and 10 % to the upper extremity. About 5 % of
all injuries affected the head/face. Interestingly, the fre-
quency of upper body injuries was higher in those studies
that analyzed match injuries only. This was mainly due to a
higher proportion of upper extremity and head/face injuries
(Table 5). Head and back injuries can have serious
consequences, particularly in children, and, thus, they
should be considered when planning preventive measures.
The proportion of upper body injuries was higher in
children under the age of 15 years (20–29 %) [32, 36, 67]
than in players older than 14 years (11–21 %) [29, 31, 35,
37, 48]. This difference was mainly due to a higher pro-
portion of upper extremity injuries (9–13 % [32, 36, 67]
and 3–8 % [31, 35, 37, 48], respectively), and fractures of
the arm, wrist, or hand (6–8 % [32, 36] and 1–3 % [31, 35,
37], respectively). A decrease in the proportion of fractures
with age has also been reported in other investigations [8,
9, 58]. Possible explanations for this observation are
skeletal immaturity and/or less developed skills and coor-
dination of younger players together with less playing
experience leading to a higher likelihood of falls, and,
consecutively, to more fractures [8].
The most common injury types were strains (muscle–
tendon injuries), sprains (joint–ligament injuries), and
contusions (Table 6). The proportion of these injury types
varied from 10 % up to 40 % between studies. Studies on
boys [32, 34–36, 40] reported a similar percentage of
strains (5–32 %) and sprains (17–33 %), while in girls [25,
29, 31, 37] more sprains (27–47 %) than strains (15–25 %)
Table 5 Distribution of injuries in different body parts
830

Reference Body part affected (%)

Lower Thigh/upper Ankle Knee Lower Foot/toe Hip/groin Upper body Trunk/ Upper Head/face
extremities leg leg spine extremities

Studies analyzing injuries over a season (match and training injuries combined)
Backous et al. [55] 71 8 19 13 10 8
Brito et al. [34] 86 30 18 12 7 13 7 14 5 7 2
Emery et al. [11] 79 6 28 19 8 8 10 21 8 4 9
Froholdt et al. [44] 76 14 20 13 9 12 8 24 12a 12
Inklaar et al. [40] 26 19 26 16
Junge et al. [35] 80 17 17 15 16 6 9 20 11 5 4
Junge et al. [26] 79 22 16 16 5 12 8 21 14 6 1
Junge et al. [59] 16 24 22 6 7b
Kakavelakis et al. [36] 80 9 29 36 6 20 5 12 3c
Le Gall et al. [31] 84 21 25 17 5 6 10 16 11 5 0.3
b
Le Gall et al. [32] 73 25 18 15 5 8 2 27 17 9 1
Müller-Rath et al. [48] 83 21 27 8 8 10 8 17 6 8 2
Nielsen and Yde [39] 15d 37 22 7
Schmidt-Olsen et al. [68] 70 23 26 11 0.3 9 14 10 4
Söderman et al. [37] 89 19 23 19 13 9 6 11 9 3
Soligard et al. [25] 8 24 27 4
Steffen et al. [29] 82 13 38 16 3b 18
Timpka et al. [65] 58 7 15 10 10 17 7 42 9 12 12
Yde and Nielsen [60] 24 27 19 19 4
All studies, median 79.5 (58–89) 16.5 (6–30) 23 17 (8–36) 8 (5–16) 9.5 7.5 20 (11–42) 10 (5–17) 6.5 (3–12) 3.5
(range) (15–38) (0.3–19) (2–10) (0.3–12)
O. Faude et al.
Football Injuries in Children and Adolescent Players 831

11.5 (5–17)
were observed. Some studies found an increase in the

Head/face
proportion of sprains and strains with age [8, 34, 44, 58].
Froholdt et al. [44] observed that sprains increased with

13

17
10
13
8c

5
age in girls, while strains increased with age in boys.
Fractures (1–15 %), dislocations (0.3–3 %), and con-
cussions (1–7 %) were less frequent. In two studies the

14 (10–15)
extremities

percentage of concussions was 6 and 7 % [11, 63],

Upper

respectively, whereas in several other studies it was 2 % or

12

14
15
15
10
less [35, 36, 41, 42, 61, 65, 68]. One of the studies with a
high frequency of concussion was conducted during a

7.5 (4–11)
tournament [63]. There is some evidence, that the risk of
Trunk/
spine

traumatic injuries, and, particularly, of sustaining a frac-

11
8

8
7
7
4

ture, contusion, or concussion as well as head, face, or

Upper body

neck injuries was higher during match play than in practice

(19–35)

sessions [62, 69]. Because of the serious consequences, a

32.5

more detailed analysis of the mechanisms resulting in

33

32
35
19

fractures and concussions in children seems warranted, in

Hip/groin

particular for the development of injury-prevention pro-

grams for this population.
In studies on football injuries presented to an emergency
4
2

department or hospital, lower extremity injuries were

13 (8–28)

fewer (40 and 50 % of all injuries) and upper extremity

Foot/toe

injuries were more frequent (30–40 % of all injuries)

13

13
10
28

[8–10]. The number of fractures and dislocations in these

8

studies was particularly high (23–31 %). Injuries to high

(6–13)
Lower

school players that resulted in absence from sport of more

9.5
leg

than 3 weeks were mainly fractures or sprains [70]. In this

13

10
9

study boys incurred more fractures (42 vs 22 %) and fewer

(10–18)

sprains (24 vs 46 %) than girls, and girls had twice as

Knee

many knee injuries as boys (50 vs 23 %) [70].

17
16

14
18
10
16

A relevant problem in young football players is also

growth-related conditions, such as osteochondral disorders
(13–22)

like Osgood-Schlatter or Sever’s disease [30, 32, 57]. Le

Ankle

Gall et al. [30, 32] found that Osgood-Schlatter disease was

20
13

16
22
16
16
Studies analyzing injuries during a tournament (match injuries only)

(together with fractures) the most common major injury in

14-year-old elite football players. The incidence of
Thigh/upper

12 (1–21)

Osgood-Schlatter syndrome peaked in the under-13 and

under-14 age groups [32, 57]. Sever’s disease has been
Body part affected (%)

12d
leg

reported to be most frequent in the under-11 age group

12
21

15
1

[57]. On average, this corresponds to growth spurts at the

beginning and the end of puberty. Thus, growth-related
injury characteristics and maturation status should be
66 (61–81)
extremities

considered when designing training and/or prevention

Lower

programs in pubescent and adolescent players. Growth-

66

61
68
65
81

related conditions, however, are often self-limiting and

Includes upper extremities
Schmidt-Olsen et al. [42]

disappear with skeletal maturation [71].

Nilsson and Roaas [47]
Rosenbaum et al. [63]

Includes groin or hip

Maehlum et al. [43]

All studies, median

Groin or hip only

Table 5 continued

Includes neck

6 Severity of Injury and Return to Play

Kibler [61]
Elias [41]
Reference

(range)

Fourteen studies reported data on the time players were not

able to fully take part in training and/or match play, or
were absent from football as a result of an injury (see
b

d
a

c
832 O. Faude et al.

Table 6 Distribution of different injury types

Reference Type of injury (%)
Strain Sprain Contusion Fracture Dislocation Concussion

Studies analyzing injuries over a season (match and training injuries combined)
Backous et al. [55] 28 16 32 1
Brito et al. [34] 31 25 23 3 3
Emery et al. [11] 24 35 6
Froholdt et al. [44] 17 24 41 5
Inklaar et al. [40] 16 33 28 2 2
Junge et al. [35] 32 21 28 1 1 1
Kakavelakis et al. [36] 23 33 21a 8 1
Le Gall et al. [31] 25 27 16 3 0.3
Le Gall et al. [32] 15 17 31b 6 1
Schmidt-Olsen et al. [68] 5 1
Söderman et al. [37] 19 32 8 3 3
Soligard et al. [25] 17 47 20 4
Steffen et al. [29] 15 43 31
Timpka et al. [65] 5 27 29 15 2
All studies, median (range) 19 (5–32) 27 (16–47) 28 (8–41) 3.5 (1–15) 1.5 (0.3–3) 1 (1–6)
Studies analyzing injuries during a tournament (match injuries only)
Elias [41] 2
Kibler [61] 25 22 32 9 2
Maehlum et al. [43] 22 47 6 1
Nilsson and Roaas [47] 36 4
Rosenbaum et al. [63] 9 32 29b 6 7
Schmidt-Olsen et al. [42] 10 20 33 4 1 1
All studies, median (range) 10 (9–25) 22 (20–32) 33 (29–47) 6 (4–9) 2 (1–7)
a
Includes abrasion
b
Includes hematoma

Table 7). For injury severity, the established consensus was
used, which defines a mild injury if the time of absence is
between 1 and 7 or 8 days, a moderate injury if the time
missed is between 7–8 and 28–30 days, and a severe injury
if the time missed is longer than 28 or 30 days. About half
of all time-loss injuries led to an absence of less than
1 week, one third resulted in an absence of between 1 and
4 weeks, and 10 to 15 % of all injuries were severe. It
should be considered that in youth football training and
match schedules are not as tight and consistent, and med-
ical care is not as comprehensive as in professional foot-
ball. Thus, the proportion of mild injuries might be
underestimated, and, consequently, the proportion of
severe injuries overestimated. Seven studies reported the
average number of days absent due to an injury as an
indicator of injury severity (Table 7) [30–34, 48, 65]. The
average duration varied, with one exception [65], between
12 and 18 days. A conclusive statement with regard to
possible differences between sexes, age groups, or level of
play is not possible from the available data.
About 1–5 % of the injuries presented to emergency
departments resulted in hospitalization and/or surgery [8–
10, 69, 72]. The risk for hospitalization and/or surgery was
higher in boys than in girls [8, 10], and higher for match
injuries than for training injuries [8, 69]. Injuries that
resulted in hospital admission mostly concerned the head,
face, or neck as well as the trunk [8]. Fatal accidents in
football are fortunately very scarce. Leininger et al. [10]
estimated the number of fatalities being about 5 per
100,000 football accidents presented to emergency
departments.
7 Summary and Potential for Injury Prevention
The incidence of injury in children’s and youth football
increased with age, and in players of both sexes aged
17–19 years the incidence approached the values observed
in adult players [16, 17, 21, 73]. For prepubertal children
very few data existed. The available studies found low
Football Injuries in Children and Adolescent Players 833

Table 7 Distribution of football injury severity as measured by inability to play or train, or length of absence from playing football
Reference Days unable to play or train (%) Days absent (mean)
Mild (\7–8 days) Moderate (7–8 to 28–30 days) Severe ([28–30 days)

Brito et al. [34] 14.6

Froholdt et al. [44] 53 NA NA
Johnson et al. [33] 12.5
Junge et al. [35] 67 NA NA
Junge et al. [26] 66 20 14
Kakavelakis et al. [36] 30 38 32
Le Gall et al. [31] 52 36 12 18
Le Gall et al. [30] 59 31 10 17.4
Le Gall et al. [32] 60 30 10 15
Müller-Rath et al. [48] 14.2
Söderman et al. [37] 34 52 14
Soligard et al. [25] 31 32 37
Steffen et al. [29] 44 NA NA
Timpka et al. [65] 27 NA NA 26.3
All studies, median (range) 52 (27–67) 32 (20–52) 14 (10–37) 15 (12.5–26.3)
No completely uniform definition of injury severity exists across studies
NA data not available or not applicable because a different definition of injury severity was used

overall (0.1 to 1.6 injuries per 1,000 h of football) [44, 74,
75] and match (about 3 or 4 injuries per 1,000 match hours)
[51] incidences for children younger than 12 years. These
data were based on low sample sizes and separate training
data were completely missing. Further research on injury
risks and patterns in the youngest children playing football
are needed to arrive at valid conclusions for injury pre-
vention in this age group.
Above the age of about 14 years, injury characteristics
tended to be similar to adult players [21, 76]. Younger
players had more fractures, fewer strains and sprains, and
the upper body was more frequently affected as compared
to their older counterparts. Skeletal and coordinative
immaturity together with growth-related diseases seem to
be more frequent, leading to specific injury characteristics.
In addition, growth-related conditions are of particular
relevance because they result in long absence from sport.
One of the pillars of prevention research is establishing
the mechanism of injury and possible risk factors [14, 15].
Most studies simply distinguished between contact and
noncontact or traumatic and overuse injuries. More detailed
information on injury mechanisms was scarcely available.
Detailed risk factor analyses and more in-depth description
of injury mechanics [77] are valuable topics for future
studies.
From the available data, it can be concluded that dif-
ferent age groups need different preventive approaches.
Adolescents showed similar injury characteristics to adult
players, and, thus, similar preventive measures might be
beneficial in this age group. Twelve studies on injury
prevention in youth and adolescent football players
(13–19 years old) were found in the literature, of which six
were designed to reduce the overall rate of injury [24–27,
78, 79] while the others focused on specific injuries [80–
85]. In most studies, there was evidence that injury-pre-
vention programs were effective [24–26, 79–83, 85]. When
an injury-prevention program failed [27, 84], poor com-
pliance was considered to be the main reason. No study
investigated the prevention of football injuries in children
under the age of 13 years.
Based on the presented data, three main areas are par-
ticularly relevant for future injury-prevention research
focusing on young football players. First, the relevant
number of severe contact injuries occurring during match
play needs to be addressed. Injuries resulting from dan-
gerous play or foul play can potentially be reduced by
applying the laws of the game and promoting fair play. Fair
play is part of the FIFA 11? prevention program, which
has been shown to be effective in reducing severe and
overall injury incidence in female youth football players
[25]. Moreover, fair play programs have been shown to be
promising approaches for reducing injuries in junior ice
hockey players [86, 87]. Nevertheless, more research on
the effectiveness of fair play in injury-prevention programs
is needed to arrive at evidence-based recommendations.
Systematic promotion of fair play by coaches, parents, and
officials should start at latest when playing organized
football. The laws of the game should be comprehensible
for young players and should be enforced on the pitch
(during match play by the referees as well as in practice
834
sessions by the coaches). Creating a safe environment
(secure goals and clearing of all debris and unneeded
obstacles) is a further step to reduce severe injuries [23].
Another relevant issue is the high number of fractures
observed in younger players. One approach might be to
reduce the risk of falling by implementing particular pre-
ventive training, focusing either on the improvement of
coordination, balance, or neuromuscular performance.
Similar approaches have been proven beneficial in adoles-
cent players [24, 80, 82, 83], but it is questionable whether
these results can be easily transferred to pubescent or even
younger children. Another promising approach might be to
teach fall techniques like those used in martial arts. Martial
arts techniques decrease the impact forces when falling, and,
thus, can reduce the consequences of falls [88, 89]. Inter-
estingly, Scase et al. [90] reported that teaching sport-spe-
cific landing skills during eight 30-min sessions during the
preseason significantly reduced the injury rate, particularly
of fall-related injuries, compared to a control group in under-
18 competitive Australian rules football players.
A third focus should be on the influence of physical
maturation status and growth spurts. In youth football,
players of a similar age but of different biological maturation
levels usually play together. Thus, some players are physi-
cally less developed than their early matured teammates and
opponents. The relative age effect (referring to the asym-
metry of birth date distribution in squads favoring players
born early in the selection year) has frequently been descri-
bed for the talent selection process [91, 92]. Although known
for a long time, no solution for this problem has been
established yet [92]. It can be assumed that the relative age
effect does not only affect talent selection and performance
but also injury risk and characteristics. However, to date
scientific evidence in this regard is lacking. Future injury
surveillance studies should provide relevant information to
address the relative age effect in relation to injury risk in
more detail. Training methods adapted to the developmental
status might help to reduce injuries and growth-related
overuse conditions. Governing bodies of football should
consider categories for youth players of similar physical
maturity instead of chronological age.
With regard to the development of injury-prevention
programs, data on specific risk factors should be considered
[14, 15]. In youth football, however, scientific information
on risk factors is limited to date [11]. Playing in adult
teams has been shown to increase the risk for anterior
cruciate ligament injury in adolescent female football
players [93]. Emery [94] summarized the literature on
injury risk factors with respect to children and adolescent
sport and concluded that evidence exists that shows poor
endurance, lack of preseason training, and psychosocial
factors being important modifiable risk factors, whereas
age, sex-specific factors, and previous injury are relevant
O. Faude et al.
nonmodifiable risk factors. The author, however, raised
concerns on the internal and external validity of these
results in children and adolescents. Particularly regarding
football injuries, previous injury within the past year and
left-leg dominance were found to be significant risk factors
in players aged 12–18 years [11]. Interestingly, Inklaar
et al. [40] observed that injury risk may be more specific to
the team than to the individual player, and, thus, preventive
measures may also target the teams and their environments.
Future research on injury risk factors in youth football is
warranted to arrive at comprehensive conclusions with
regard to the development of prevention programs.
8 Methodological Issues
The studies included in present review vary considerably in
injury definitions and data collection procedures, which has
made comparisons between studies difficult or impossible.
For instance, some authors combined sprains and strains,
others injuries of thigh and lower leg, injuries in boys and
girls, or match and training injuries, and some pooled
injuries of all age groups. Such limitations are inherent
when comparing projects across a 35-year period [95].
In contrast to professional football players who often have
team physicians and/or physiotherapists, the injury surveil-
lance of children is more difficult due to the lack of medical
coverage. Thus, critical evaluation of injury monitoring is
necessary and uniform methodological standards need to be
established. Many minor injuries do not lead to time loss
(missing organized football sessions or physical education
lessons in school) and might not be presented to a physician;
thus, exact medical diagnoses are not always available.
Because the injury incidence in children is among the lowest
reported in football, large numbers of teams need to be fol-
lowed carefully to obtain reliable data on injury risk. Fre-
quent recording and reporting of injury by a specifically
identified individual (e.g., a coach or research team member)
is recommended [22], and has been successfully conducted
in this age group [44]. In addition, more information on
specific injury circumstances as well as more precise infor-
mation on population characteristics (e.g., exact age of
players, level of play, fitness level, anthropometric data),
and, in particular, more detailed analyses of injury charac-
teristics, mechanisms, and risk factors within specific age
groups seem to be warranted in future research.
9 Conclusions and Recommendations for Future
Research
While many studies on the incidence, characteristics,
mechanisms, and prevention of football injuries in adult
Football Injuries in Children and Adolescent Players
and adolescent players have been published in recent
decades, there is a remarkable lack of information on
football injuries and their prevention for players younger
than 13 years. The widely accepted consensus for epide-
miological studies on football injuries [22] should serve as
the methodological foundation for future projects, but
needs to be partly adapted to the specific conditions in
children’s and youth football. Future studies should pay
attention to injury mechanisms, risk factors, and overuse
injuries [64]. Due to the different injury profile and mat-
uration status of children, preventive programs that have
proven effective in late adolescent or adult players need to
be adapted and their effects evaluated in younger age
groups. Injury rates in young children may be the lowest
within the sport, but due to the high number of participants
injury-prevention programs can result in a substantial
public health impact with outcomes similar to a recent
successful national implementation of a football prevention
program [96].
All epidemiological studies on football injuries of chil-
dren and youth players (Tables 1, 2) were conducted in
developed countries, mostly in North America and Europe.
Investigations on risk and prevention of football injuries in
developing and emerging countries where organizational
structures and environmental conditions can be very dif-
ferent are completely missing. An expansion of campaigns
to prevent communicable and noncommunicable diseases
in selected African countries [97] might be a promising
foundation for future projects on injury risk and prevention
in these regions of the world.
Emery and colleagues [98] pointed out that the child
should be at the center of all efforts to reduce injuries.
Parents, coaches, and professional players should be role
models with regard to injury prevention and fair play.
Parents should provide their children with safe protective
equipment and coaches should include injury-prevention
strategies into training and provide a safe environment.
The governing bodies of football should promote injury
prevention and enforce the strict application of the laws
of the game. Prevention strategies should be properly
integrated throughout this spectrum to reduce the injury
risk in football, and thereby reduce risk compensation
behavior by athletes [99]. Froholdt and colleagues [44]
emphasized that ‘‘it is important to develop good habits,
for example, by using appropriate warm-up programs,
correct playing technique, and focusing on fair play atti-
tudes from an early age,’’ (p. 1159). Also, Verhagen et al.
[100] pointed out the relevance of behavioral approaches
for sports injury prevention in a real-life setting. Future
injury-prevention strategies, thus, need a broader research
focus. Children usually are regarded as the future of our
society, and, therefore, their health should be of particular
importance.
835
Acknowledgments Oliver Faude and Astrid Junge were responsible
for the concept of the article and wrote the first draft of the manu-
script. Roland Rößler was involved in the literature search and in data
extraction. All authors contributed to the final article by reading and
correcting the draft version. We thank Don Kirkendall for his input on
an earlier draft of this review as well as all reviewers and the
responsible editor for their valuable and constructive comments on
the first submitted version of this manuscript. All authors declare that
they have no conflict of interest that is directly relevant to the content
of this review. Astrid Junge is employed by F-MARC (FIFA-Medical
Assessment and Research Centre). The authors gratefully acknowl-
edge FIFA (Fédération Internationale de Football Association) for the
funding of the study.
References
1. FIFA Communications Division. FIFA big count 2006: 270
million people active in football. Zurich: 2007.
2. FIFA. Almost half the world tuned in at home to watch 2010
FIFA World Cup South AfricaTM. Zurich2011 (cited 12 Oct
2012). Available from: http://www.fifa.com/worldcup/archive/
southafrica2010/organisation/media/newsid=1473143/index.html.
3. Krustrup P, Nielsen JJ, Krustrup B, et al. Recreational soccer is
an effective health promoting activity for untrained men. Br J
Sports Med. 2009;43(11):825–31.
4. Faude O, Kerper O, Multhaupt M, et al. Football to tackle
overweight in children. Scand J Med Sci Sports. 2010;20(Suppl
1):103–10.
5. Krustrup P, Hansen PR, Andersen LJ, et al. Long-term muscu-
loskeletal and cardiac health effects of recreational football and
running for premenopausal women. Scand J Med Sci Sports.
2010;20(Suppl 1):58–71.
6. Krustrup P, Aagaard P, Nybo L, et al. Recreational football as a
health promoting activity: a topical review. Scand J Med Sci
Sports. 2010;20(Suppl 1):1–13.
7. Weintraub DL, Tirumalai EC, Haydel KF, et al. Team sports for
overweight children: the Stanford sports to prevent obesity
randomized trial (SPORT). Arch Pediatr Adolesc Med.
2008;162(3):232–7.
8. Giannotti M, Al-Sahab B, McFaull S, et al. Epidemiology of
acute soccer injuries in Canadian children and youth. Pediatr
Emerg Care. 2011;27(2):81–5.
9. Adams AL, Schiff MA. Childhood soccer injuries treated in US
emergency departments. Acad Emerg Med. 2006;13(5):571–4.
10. Leininger RE, Knox CL, Comstock RD. Epidemiology of
1.6 million pediatric soccer-related injuries presenting to US
emergency departments from 1990 to 2003. Am J Sports Med.
2007;35(2):288–93.
11. Emery CA, Meeuwisse WH, Hartmann SE. Evaluation of risk
factors for injury in adolescent soccer: implementation and
validation of an injury surveillance system. Am J Sports Med.
2005;33(12):1882–91.
12. Lohmander LS, Ostenberg A, Englund M, et al. High prevalence
of knee osteoarthritis, pain, and functional limitations in female
soccer players twelve years after anterior cruciate ligament
injury. Arthritis Rheum. 2004;50(10):3145–52.
13. Kartal A, Yildiran I, Senkoylu A, et al. Soccer causes degenerative
changes in the cervical spine. Eur Spine J. 2004;13(1):76–82.
14. Bahr R, Krosshaug T. Understanding injury mechanisms: a key
component of preventing injuries in sport. Br J Sports Med.
2005;39(6):324–9.
15. van Mechelen W, Hlobil H, Kemper HC. Incidence, severity,
aetiology and prevention of sports injuries. A review of con-
cepts. Sports Med. 1992;14(2):82–99.
836
16. Ekstrand J, Hagglund M, Walden M. Injury incidence and injury
patterns in professional football: the UEFA injury study. Br J
Sports Med. 2011;45(7):553–8.
17. Faude O, Junge A, Kindermann W, et al. Injuries in female
soccer players: a prospective study in the German national
league. Am J Sports Med. 2005;33(11):1694–700.
18. Hagglund M, Walden M, Ekstrand J. UEFA injury study—an
injury audit of European Championships 2006 to 2008. Br J
Sports Med. 2009;43(7):483–9.
19. Junge A, Dvorak J, Graf-Baumann T. Football injuries during the
World Cup 2002. Am J Sports Med. 2004;32(1 Suppl):23S–7S.
20. Walden M, Hagglund M, Werner J, et al. The epidemiology of
anterior cruciate ligament injury in football (soccer): a review of
the literature from a gender-related perspective. Knee Surg
Sports Traumatol Arthrosc. 2011;19(1):3–10.
21. Junge A, Dvorak J. Soccer injuries: a review on incidence and
prevention. Sports Med. 2004;34(13):929–38.
22. Fuller CW, Ekstrand J, Junge A, et al. Consensus statement on
injury definitions and data collection procedures in studies of
football (soccer) injuries. Br J Sports Med. 2006;40(3):193–201.
23. Giza E, Micheli LJ. Soccer injuries. Med Sport Sci. 2005;49:
140–69.
24. Emery CA, Meeuwisse WH. The effectiveness of a neuromus-
cular prevention strategy to reduce injuries in youth soccer: a
cluster-randomised controlled trial. Br J Sports Med. 2010;
44(8):555–62.
25. Soligard T, Myklebust G, Steffen K, et al. Comprehensive
warm-up programme to prevent injuries in young female foot-
ballers: cluster randomised controlled trial. BMJ. 2008;337:
a2469.
26. Junge A, Rosch D, Peterson L, et al. Prevention of soccer
injuries: a prospective intervention study in youth amateur
players. Am J Sports Med. 2002;30(5):652–9.
27. Steffen K, Myklebust G, Olsen OE, et al. Preventing injuries in
female youth football—a cluster-randomized controlled trial.
Scand J Med Sci Sports. 2008;18(5):605–14.
28. Soligard T, Grindem H, Bahr R, et al. Are skilled players at
greater risk of injury in female youth football? Br J Sports Med.
2010;44(15):1118–23.
29. Steffen K, Andersen TE, Bahr R. Risk of injury on artificial turf
and natural grass in young female football players. Br J Sports
Med. 2007;41(Suppl 1):i33–7.
30. Le Gall F, Carling C, Reilly T. Biological maturity and injury in
elite youth football. Scand J Med Sci Sports. 2007;17(5):
564–72.
31. Le Gall F, Carling C, Reilly T. Injuries in young elite female
soccer players: an 8-season prospective study. Am J Sports Med.
2008;36(2):276–84.
32. Le Gall F, Carling C, Reilly T, et al. Incidence of injuries in elite
French youth soccer players: a 10-season study. Am J Sports
Med. 2006;34(6):928–38.
33. Johnson A, Doherty PJ, Freemont A. Investigation of growth,
development, and factors associated with injury in elite
schoolboy footballers: prospective study. BMJ. 2009;338:b490.
34. Brito J, Malina RM, Seabra A, et al. Injuries in Portuguese youth
soccer players during training and match play. J Athl Train.
2012;47(2):191–7.
35. Junge A, Cheung K, Edwards T, et al. Injuries in youth amateur
soccer and rugby players—comparison of incidence and char-
acteristics. Br J Sports Med. 2004;38(2):168–72.
36. Kakavelakis KN, Vlazakis S, Vlahakis I, et al. Soccer injuries in
childhood. Scand J Med Sci Sports. 2003;13(3):175–8.
37. Söderman K, Adolphson J, Lorentzon R, et al. Injuries in ado-
lescent female players in European football: a prospective study
over one outdoor soccer season. Scand J Med Sci Sports.
2001;11(5):299–304.
O. Faude et al.
38. Peterson L, Junge A, Chomiak J, et al. Incidence of football
injuries and complaints in different age groups and skill-level
groups. Am J Sports Med. 2000;28(5 Suppl):S51–7.
39. Nielsen AB, Yde J. Epidemiology and traumatology of injuries
in soccer. Am J Sports Med. 1989;17(6):803–7.
40. Inklaar H, Bol E, Schmikli SL, et al. Injuries in male soccer
players: team risk analysis. Int J Sports Med. 1996;17(3):
229–34.
41. Elias SR. 10-year trend in USA Cup soccer injuries: 1988–1997.
Med Sci Sports Exerc. 2001;33(3):359–67.
42. Schmidt-Olsen S, Bunemann LK, Lade V, et al. Soccer injuries
of youth. Br J Sports Med. 1985;19(3):161–4.
43. Maehlum S, Dahl E, Daljord O. Frequency of injuries in a youth
soccer tournament. Phys Sportsmed. 1986;14:73–9.
44. Froholdt A, Olsen OE, Bahr R. Low risk of injuries among
children playing organized soccer: a prospective cohort study.
Am J Sports Med. 2009;37(6):1155–60.
45. Aoki H, Kohno T, Fujiya H, et al. Incidence of injury among
adolescent soccer players: a comparative study of artificial and
natural grass turfs. Clin J Sport Med. 2010;20(1):1–7.
46. McNoe BM, Chalmers DJ. Injury in community-level soccer:
development of an injury surveillance system. Am J Sports Med.
2010;38(12):2542–51.
47. Nilsson S, Roaas A. Soccer injuries in adolescents. Am J Sports
Med. 1978;6(6):358–61.
48. Müller-Rath R, Schmidt C, Mumme T, et al. The injury pattern
following the introduction of the junior premier league in Ger-
many compared to professional senior football (soccer).
Sportverletz Sportschaden. 2006;20(4):192–5.
49. Emery CA, Meeuwisse WH. Risk factors for injury in indoor
compared with outdoor adolescent soccer. Am J Sports Med.
2006;34(10):1636–42.
50. Lindenfeld TN, Schmitt DJ, Hendy MP, et al. Incidence of
injury in indoor soccer. Am J Sports Med. 1994;22(3):364–71.
51. Hoff GL, Martin TA. Outdoor and indoor soccer: injuries among
youth players. Am J Sports Med. 1986;14(3):231–3.
52. Fuller CW, Dick RW, Corlette J, et al. Comparison of the
incidence, nature and cause of injuries sustained on grass and
new generation artificial turf by male and female football
players. Part 2: training injuries. Br J Sports Med. 2007;41
(Suppl 1):i27–32.
53. Fuller CW, Dick RW, Corlette J, et al. Comparison of the
incidence, nature and cause of injuries sustained on grass and
new generation artificial turf by male and female football players.
Part 1: match injuries. Br J Sports Med. 2007;41(Suppl 1):i20–6.
54. Soligard T, Bahr R, Andersen TE. Injury risk on artificial turf
and grass in youth tournament football. Scand J Med Sci Sports.
2012;22(3):356–61.
55. Backous DD, Friedl KE, Smith NJ, et al. Soccer injuries and their
relation to physical maturity. Am J Dis Child. 1988;142(8):
839–42.
56. Baxter-Jones A, Maffulli N, Helms P. Low injury rates in elite
athletes. Arch Dis Child. 1993;68(1):130–2.
57. Price RJ, Hawkins RD, Hulse MA, et al. The Football Associ-
ation medical research programme: an audit of injuries in
academy youth football. Br J Sports Med. 2004;38(4):466–71.
58. Berger-Vachon C, Gabard G, Moyen B. Soccer accidents in the
French Rhone-Alpes Soccer Association. Sports Med. 1986;3(1):
69–77.
59. Junge A, Chomiak J, Dvorak J. Incidence of football injuries in
youth players. Comparison of players from two European
regions. Am J Sports Med. 2000;28(5 Suppl):S47–50.
60. Yde J, Nielsen AB. Sports injuries in adolescents’ ball games:
soccer, handball and basketball. Br J Sports Med. 1990;24(1):51–4.
61. Kibler WB. Injuries in adolescent and preadolescent soccer
players. Med Sci Sports Exerc. 1993;25(12):1330–2.
Football Injuries in Children and Adolescent Players
62. Yard EE, Schroeder MJ, Fields SK, et al. The epidemiology of
United States high school soccer injuries, 2005–2007. Am J
Sports Med. 2008;36(10):1930–7.
63. Rosenbaum DA, Silvis ML, Williams JE, et al. Variation in
injury risk over the course of a two-day youth club soccer
tournament. Inj Prev. 2009;15(4):266–9.
64. Bahr R. No injuries, but plenty of pain? On the methodology for
recording overuse symptoms in sports. Br J Sports Med.
2009;43(13):966–72.
65. Timpka T, Risto O, Bjormsjo M. Boys soccer league injuries: a
community-based study of time-loss from sports participation
and long-term sequelae. Eur J Public Health. 2008;18(1):19–24.
66. Kucera KL, Marshall SW, Kirkendall DT, et al. Injury history as
a risk factor for incident injury in youth soccer. Br J Sports Med.
2005;39(7):462.
67. Schiff MA. Soccer injuries in female youth players. J Adolesc
Health. 2007;40(4):369–71.
68. Schmidt-Olsen S, Jorgensen U, Kaalund S, et al. Injuries among
young soccer players. Am J Sports Med. 1991;19(3):273–5.
69. Rechel JA, Yard EE, Comstock RD. An epidemiologic com-
parison of high school sports injuries sustained in practice and
competition. J Athl Train. 2008;43(2):197–204.
70. Darrow CJ, Collins CL, Yard EE, et al. Epidemiology of severe
injuries among United States high school athletes: 2005–2007.
Am J Sports Med. 2009;37(9):1798–805.
71. Gholve PA, Scher DM, Khakharia S, et al. Osgood Schlatter
syndrome. Curr Opin Pediatr. 2007;19(1):44–50.
72. Powell JW, Barber-Foss KD. Injury patterns in selected high
school sports: a review of the 1995–1997 seasons. J Athl Train.
1999;34(3):277–84.
73. Ekstrand J, Hagglund M, Fuller CW. Comparison of injuries
sustained on artificial turf and grass by male and female elite
football players. Scand J Med Sci Sports. 2011;21(6):824–32.
74. de Loes M, Goldie I. Incidence rate of injuries during sport
activity and physical exercise in a rural Swedish municipality:
incidence rates in 17 sports. Int J Sports Med. 1988;9(6):461–7.
75. Spinks AB, Macpherson AK, Bain C, et al. Injury risk from
popular childhood physical activities: results from an Australian
primary school cohort. Inj Prev. 2006;12(6):390–4.
76. Hagglund M, Walden M, Ekstrand J. Injuries among male and female
elite football players. Scand J Med Sci Sports. 2009;19(6):819–27.
77. Krosshaug T, Andersen TE, Olsen OE, et al. Research approa-
ches to describe the mechanisms of injuries in sport: limitations
and possibilities. Br J Sports Med. 2005;39(6):330–9.
78. Soligard T, Nilstad A, Steffen K, et al. Compliance with a
comprehensive warm-up programme to prevent injuries in youth
football. Br J Sports Med. 2010;44(11):787–93.
79. Heidt RS Jr, Sweeterman LM, Carlonas RL, et al. Avoidance of
soccer injuries with preseason conditioning. Am J Sports Med.
2000;28(5):659–62.
80. Hewett TE, Lindenfeld TN, Riccobene JV, et al. The effect of neu-
romuscular training on the incidence of knee injury in female ath-
letes. A prospective study. Am J Sports Med. 1999;27(6):699–706.
81. Kiani A, Hellquist E, Ahlqvist K, et al. Prevention of soccer-
related knee injuries in teenaged girls. Arch Intern Med.
2010;170(1):43–9.
82. Mandelbaum BR, Silvers HJ, Watanabe DS, et al. Effectiveness
of a neuromuscular and proprioceptive training program in
preventing anterior cruciate ligament injuries in female athletes:
2-year follow-up. Am J Sports Med. 2005;33(7):1003–10.
83. McGuine TA, Keene JS. The effect of a balance training pro-
gram on the risk of ankle sprains in high school athletes. Am J
Sports Med. 2006;34(7):1103–11.
84. Pfeiffer RP, Shea KG, Roberts D, et al. Lack of effect of a knee
ligament injury prevention program on the incidence of
837
noncontact anterior cruciate ligament injury. J Bone Joint Surg
Am. 2006;88(8):1769–74.
85. Walden M, Atroshi I, Magnusson H, et al. Prevention of acute
knee injuries in adolescent female football players: cluster ran-
domised controlled trial. BMJ. 2012;344:e3042.
86. Roberts WO, Brust JD, Leonard B, et al. Fair-play rules and
injury reduction in ice hockey. Arch Pediatr Adolesc Med.
1996;150(2):140–5.
87. Brunelle JP, Goulet C, Arguin H. Promoting respect for the rules
and injury prevention in ice hockey: evaluation of the fair-play
program. J Sci Med Sport. 2005;8(3):294–304.
88. Groen BE, Weerdesteyn V, Duysens J. Martial arts fall tech-
niques decrease the impact forces at the hip during sideways
falling. J Biomech. 2007;40(2):458–62.
89. Sabick MB, Hay JG, Goel VK, et al. Active responses decrease
impact forces at the hip and shoulder in falls to the side. J Bio-
mech. 1999;32(9):993–8.
90. Scase E, Cook J, Makdissi M, et al. Teaching landing skills in elite
junior Australian football: evaluation of an injury prevention
strategy. Br J Sports Med 2006;40(10):834–8 (discussion 8).
91. Helsen WF, van Winckel J, Williams AM. The relative age
effect in youth soccer across Europe. J Sports Sci. 2005;23(6):
629–36.
92. Helsen WF, Baker J, Michiels S, et al. The relative age effect in
European professional soccer: did ten years of research make
any difference? J Sports Sci. 2012;30(15):1665–71.
93. Söderman K, Pietila T, Alfredson H, et al. Anterior cruciate
ligament injuries in young females playing soccer at senior
levels. Scand J Med Sci Sports. 2002;12(2):65–8.
94. Emery CA. Risk factors for injury in child and adolescent sport:
a systematic review of the literature. Clin J Sport Med.
2003;13(4):256–68.
95. Junge A, Dvorak J. Influence of definition and data collection on
the incidence of injuries in football. Am J Sports Med.
2000;28(5 Suppl):S40–6.
96. Junge A, Lamprecht M, Stamm H, et al. Countrywide campaign
to prevent soccer injuries in Swiss amateur players. Am J Sports
Med. 2011;39(1):57–63.
97. Dvorak J, Fuller CW, Junge A. Planning and implementing a
nationwide football-based health-education programme. Br J
Sports Med. 2012;46(1):6–10.
98. Emery CA, Hagel B, Morrongiello BA. Injury prevention in
child and adolescent sport: whose responsibility is it? Clin J
Sport Med. 2006;16(6):514–21.
99. Hagel B, Meeuwisse W. Risk compensation: a ‘‘side effect’’ of
sport injury prevention? Clin J Sport Med. 2004;14(4):193–6.
100. Verhagen EA, van Stralen MM, van Mechelen W. Behaviour,
the key factor for sports injury prevention. Sports Med.
2010;40(11):899–906.
101. Dahlstrom O, Backe S, Ekberg J, et al. Is ‘‘football for all’’ safe
for all? Cross-sectional study of disparities as determinants of
1-year injury prevalence in youth football programs. PLoS ONE.
2012;7(8):e43795.
102. Kujala UM, Taimela S, Antti-Poika I, et al. Acute injuries in
soccer, ice hockey, volleyball, basketball, judo, and karate:
analysis of national registry data. BMJ. 1995;311(7018):1465–8.
103. Radelet MA, Lephart SM, Rubinstein EN, et al. Survey of the
injury rate for children in community sports. Pediatrics.
2002;110(3):e28.
104. Schmikli SL, de Vries WR, Inklaar H, et al. Injury prevention
target groups in soccer: injury characteristics and incidence rates
in male junior and senior players. J Sci Med Sport.
2011;14(3):199–203.
105. Sullivan JA, Gross RH, Grana WA, et al. Evaluation of injuries
in youth soccer. Am J Sports Med. 1980;8(5):325–7.